Referral Form for Greenwich Time To Talk IAPT Adult Primary Care Psychology Service
Personal Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Not specified
Not known
If you are a 16/17 year old, or a parent of a 16/17 year old, please answer these questions:
PARENT: Are you making this referral on behalf of the young person?
Yes
No
N/A
If you have answered yes, has the young person given permission for you to make this referral?
Yes
No
N/A
YOUNG PERSON: Are your parents/carers aware that you are making this referral?*
Yes
No
N/A
If yes, do we have your consent to speak to your parents on your behalf?*
Yes
No
N/A
NHS Number:
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Email Address:
Phone Number:
Phone Type:
Please Select A Value...
Home Phone
Work Phone
Other Phone
Can a message be left?:
Yes
No
Mobile Number:
Can a message be left?:
Yes
No
Can we send Text Message reminders?:
Yes
No
Would you like to have any of your appointments via video call (similar to Skype)?*
Yes
No
Please indicate the preferred time(s) of day for us to contact you for an assessment:*
Am
Pm
Please indicate the preferred assessment method(s):*
Telephone
Face-To-Face
Do you have a long term medical condition? (e.g. cancer, diabetes, heart disease, stroke):*
Please Select A Value...
Yes
No
Don't Know/Not Sure
Do not wish to say
If Yes, please describe:
Do you have a disability?:*
Please Select A Value...
No Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
Other
Do not wish to say
Do you have any specific needs we need to be aware of?:
GP Details
Registered GP Name:*
Registered GP Surgery Name and Address:*
Referral Information
Are you currently a mental health inpatient under the care of a Community Mental Health Team or receiving psychological therapies elsewhere?:*
Yes
No
Please select from the following drop down list the reason that best describes why you are referring:*
Please Select A Value...
Depression
Anxiety
Panic
Health Anxiety
Social Phobia
Obsessive Compulsive Disorder (OCD)
Post Traumatic Stress Disorder (PTSD)
Other
Where did you hear about us?:*
Please Select A Value...
MIND
Other
From a family member
Information in a practice
From a professional
GP recommended the service
Information taken from a community place
Previous service user
CAMHS recommended service
A&E Department
To complete the below fields, please use the online self-assessment tool to calculate your scores.
Please enter your PHQ-9 score:*
Please enter your GAD-7 score:*
What will happen next?
1 – Our admin team will telephone you on the numbers you have provided to book your first appointment
2 – A clinician will do an assessment with you to find out what your main problem is and see if we can help
3 – You will be placed on our waiting list and called as soon as an appointment becomes available
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